Childhood sexual abuse can be defined as any exposure
to sexual acts imposed on children who inherently
lack the emotional, maturational, and cognitive
development to understand or to consent to such
acts. These acts do not always involve sexual
intercourse or physical force; rather, they involve
manipulation and trickery. Authority and power
enable the perpetrator to coerce the child into
compliance. Characteristics and motivations of
perpetrators of childhood sexual abuse vary: some
may act out sexually to exert dominance over another
individual; others may initiate the abuse for
their own sexual gratification (5, 6).

Although specific legal definitions may vary among
states, there is widespread agreement that abusive
sexual contact can include breast and genital
fondling, oral and anal sex, and vaginal intercourse.
Definitions have been expanded to include noncontact
events such as coercion to watch sexual acts or
posing in child pornography (7).

Prevalence

The prevalence of childhood sexual abuse in the
United States is unknown. Because of the shame
and stigma associated with abuse, many victims
never disclose such experiences. Incest was once
thought to be so rare that its occurrence was
inconsequential. However, in the past 25 years
there has been increased recognition that incest
and other forms of childhood sexual abuse occur
with alarming frequency (8). Researchers have
found that victims come from all cultural, racial,
and economic groups (9).

Current estimates of incest and other childhood
sexual abuse range from 12% to 40% depending on
settings and population. Most studies have found
that among women, approximately 20% - or 1 in
5 - have experienced childhood sexual abuse (9).
Consistent with this range, studies have revealed
that:

Among girls who had sex before they were 13 years
old, 22% reported that first sex was nonvoluntary
(10).

Twelve percent of girls in grades 9 through 12
reported they had been sexually abused; 7% of
girls in grades 5 through 8 also reported sexual
abuse. Of all the girls who experienced sexual
abuse, 65% reported the abuse occurred more than
once, 57% reported the abuser was a family member,
and 53% reported the abuse occurred at home (11).

Approximately 40% of the women surveyed in a primary
care setting had experienced some form of childhood
sexual contact; of those, 1 in 6 had been raped
as a child (12).

A national telephone survey on violence against
women conducted by the National Institute of Justice
and the Centers for Disease Control and Prevention
found that 18% of 8,000 women surveyed had experienced
a completed or attempted rape at some time in
their lives. Of this number, 22% were younger
than 12 years and 32% were between 12 and 17 years
old when they were first raped (9).

Common Symptoms in Adult Survivors of Childhood
Sexual Abuse:

Physical Presentations

Chronic pelvic pain

Gastrointestinal symptoms/distress

Musculoskeletal complaints

Obesity, eating disorders

Insomnia, sleep disorders

Pseudocyesis

Sexual dysfunction

Asthma, respiratory ailments

Addiction

Chronic headache

Chronic back pain

Psychologic and Behavioral
Presentations

Depression and anxiety

Posttraumatic stress disorder
symptoms

Dissociative states

Repeated self-injury

Suicide attempts

Lying, stealing, truancy, running
away

Poor contraceptive practices

Compulsive sexual behaviors

Sexual dysfunction

Somatizing disorders

Eating disorders

Poor adherence to medical recommendations

Intolerance of or constant
search for intimacy

Expectation of early death

Although there is no single syndrome that is universally
present in adult survivors of childhood sexual
abuse, there is an extensive body of research
that documents adverse short- and long-term effects
of such abuse. To appropriately treat and manage
survivors of CSA, it is useful to understand that
survivors' symptoms or behavioral sequelae often
represent coping strategies employed in response
to abnormal, traumatic events. These coping mechanisms
are used for protection during the abuse or later
to guard against feelings of overwhelming helplessness
and terror. Although some of these coping strategies
may eventually lead to health problems, if symptoms
are evaluated outside their original context,
survivors may be misdiagnosed or mislabeled (5).

In addition to the psychologic distress that may
potentiate survivors' symptoms, there is evidence
that abuse may result in biophysical changes.
For example, one study found that, after controlling
for history of psychiatric disturbance, adult
survivors had lowered thresholds for pain (13).
It also has been suggested that chronic or traumatic
stimulation (especially in the pelvic or abdominal
region) heightens sensitivity, resulting in persistent
pain such as abdominal and pelvic pain or other
bowel symptoms (14, 15).

Although responses to sexual abuse vary, there
is remarkable consistency in mental health symptoms,
especially depression and anxiety. These mental
health symptoms may be found alone or more often
in tandem with physical and behavioral symptoms.
More extreme symptoms are associated with abuse
onset at an early age, extended or frequent abuse,
incest by a parent, or use of force (4). Responses
may be mitigated by such factors as inherent resiliency
or supportive responses from individuals who are
important to the victim (4). Even without therapeutic
intervention, some survivors maintain the outward
appearance of being unaffected by their abuse.
Most, however, experience pervasive and deleterious
consequences (4).

The primary aftereffects of childhood sexual abuse
have been divided into seven distinct, but overlapping
categories (16):

Emotional reactions

Symptoms of posttraumatic stress
disorder (PTSD)

Self-perceptions

Physical and biomedical effects

Sexual effects

Interpersonal effects

Social functioning

Responses can be greatly variable
and idiosyncratic within the seven categories.
Also, survivors may fluctuate between being highly
symptomatic and relatively symptom free. Health
care providers should be aware that such variability
is normal.

Tjaden P, Thoennes N. Prevalence, incidence,
and consequences of violence against women:
findings from the National Violence Against
Women Survey. Research in Brief. Washington,
DC: U.S. Dept of Justice, Office of Justice
Programs, November 1998, NCJ 172837

Moore KA, Driscoll A. Partners, predators, peers,
protectors: males and teen pregnancy. New data
analysis of the 1995 National Survey of Family
Growth. In: Not just for girls: the roles of
boys and men in teen pregnancy. Washington,
DC: The National Campaign to Prevent Teen Pregnancy,
1997: 7-12